Welcome to WINSLOW INSURANCE AGENCY! 

Do you need insurance for your Business, Home, Life or Medical Insurance in TEXAS, or the Nation, we at The Winslow Insurance Agency specialize in personal & business insurance throughout the state of Texas and the Nation.  Whether you need any kind of insurance for your business, home, life or health, we can provide you with a competitive quote.  You'll also receive quality customer service with our business insurance including work comp, commercial auto, and group health.

Quote Forms:
Customer Service:

Workers Compensation Insurance Quote Form

First & Last Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
Fax:  

Current Insurance Information
Insurance Company Name:  
Any losses in last 3 years?:  
# of claims:  
Claim amt. pd $:  
Premium Amount:  
Policy Exp. Date:  
MOD Factor:  
Policy #:  
Describe the type of Coverage you currently have:  

Prior Carrier Info
Insurance Company Name:  
# of claims:  
Claim amt. pd $:  
Premium Amount:  
How many years with:  
MOD Factor:  
Policy #:  

About Your Business
# of Full-time:  
# of Part-time:  
Owner's Name:  
Fed Tax ID:  
License Type:  
Yrs in Business:  
License #:  
# of locations:  
Annual Gross Sales:  
Square Footage:  
Est payroll / mo.:  
Type of Business:  
Please describe your business here:  

Owners / Partner / Officers
Name
Date of Birth
Title
Ownership %

Payroll Information
Class Codes
Employee Duties
Annual Payroll $
Hourly Wage $

General Information
Do you offer safety programs?
Do offer health benefits to majority of employees?  
Do employ any minors (under 18)?  
Is operation all/part of existing business that was purchased/acq.?
Do you use subcontractors?  
Use any equipment that bends/shapes/forms?  
Are athletic teams sponsored?  
Been a lapse in coverage during past 12 months?  
Any work above 15 feet?  
Had a bankruptcy in past 7 years?  
Are a member of any trade organizations?  

Additional Information:
Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for.